73 - Videositzung
16. Mai 2019, 17:30 - 19:00, Bellavista 2, 6. OG
Uniportal thoracoscopic anatomical left S3-segmentectomy: Follow the vein (video)
K. Gioutsos, R. A. Schmid, J. A. Lutz, Presenter: K. Gioutsos (Bern)
Pulmonary segmentectomies using minimally invasive techniques are gaining ground, not only for the treatment of early stage, peripherally located non-small cell lung cancer (NSCLC) but also for synchronous NSCLC or NSCLC with limited lung reserve (compromised segmentectomies), as well as for centrally located metastasis. Segmental resections of the apical segments of the lower lobe or of the lingula for example are considered straightforward. Other segmentectomies remain a technical challenge. This video exhibits the anatomical landmarks and key steps for a left S3-Segmentectomy.
Six cases of left-sided uniportal thoracoscopic anatomical S3-Segmentectomies were performed during 2018 and we reviewed the recorded videos to illustrate the technique used. Dissection began on the mediastinal side to identify the upper vein with its trifurcation. V3c-branch was cut with vascular stapler or with clip and energy device depending of its size, revealing the A3 artery and B3 bronchus. The segmental artery was then transected followed by the B3 bronchus (after ventilation control). The intersegmental plane between S3 and S4+5 (lingula) was divided using a stapler device after tunnelling along V3b, sometimes up to the interlobar fissure. Finally, the parenchyma between S1+2 and S3 was separated (stapler). For the parenchymal steps, the use of ICG fluoroscopy can be helpful.
Indications for S3-Segmentectomy were suspicion of Stage IA NSCLC in 4 cases, a synchronous NSCLC and a central metastasis of a chondrosarcoma. No conversion or extension of the planned procedure was necessary. There was no 30-day or in-hospital morbidity observed and all patients recovered uneventfully, being discharged between postoperative day 2 and 4. The final pathological results confirmed the suspicion of NSCLC in 2 cases, the other 2 being central metastasis of a neck tumor respectively a skin tumor.
For isolated segmentectomies boarding more than one segment like S3 in this case, preparation along the intersegmental vein is mandatory to identify properly the plane between the segments. It also allows more space for better preparation of the arterial and bronchial pedicle of the resected segment.